Door-to-Door Smoke Alarm Action Form

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Door-to-Door Smoke Alarm Action Form Powered By Docstoc
					Introduce your team and your purpose.     Example: “Hello, we are with [Department
Name] fire department. We are checking with you today to see if your home has
working smoke alarms.     A working smoke alarm can alert you and your family to a
fire and save your life. Would you like us to test your smoke alarms? We will
replace those alarms not working at no charge to you.” Use the Action Form below to
record answers to questions about the home and resident(s):


 STREET ADDRESS OF HOME:

 QUESTION                                    CIRCLE ANSWER         WRITE RESPONSE

 Type of Home                                Single    Duplex      Other:
                                             Family

 Do you rent or own?                         Rent      Own         Other:

 Number of stories                           1         2           Other:

 How many smoke alarms do you have?          1         2           Other:

 Do you know how old the alarms are?         Yes       No          Age of alarm:

 Is there an alarm on each floor?            Yes       No

 In each bedroom?                            Yes       No

 How often do test your smoke alarms?        Weekly    Monthly     Other:

 How many smoke alarms are working?          Yes       No
 Would you like us to check them for
 you?

 If yes, how many alarms were working?       1         2           Other:

 How many alarms did the team install?       1         2           Other:

 Did the team leave fire safety              Yes       No
 information?

 If children were in the home, did the       Yes       No
 team alert the parent that many
 children sleep through a beeping
 smoke alarm?

 If the resident was not home, did the       Yes       No
 team leave a door hangar?



Completed by    _______________________________________________________     Date
____________

The following information is need for landlord/owner reimbursement:
Name of Building Owner:          Mailing Address:                State:
Phone:   City:   Zip: